Part 5: Looking for the cracks in medicare? Try the Ontario-Quebec border
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The act guarantees universal health care, setting out key principles of access and affordability - one of which suffers from a serious case of neglect.

Under the portability requirement, every Canadian is entitled to full medical coverage, no matter where he or she lives, and provincial health insurance plans are supposed to be good anywhere in the country.

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But that tenet is showing cracks at the Quebec-Ontario boundary. Quebec patients are turned away or pay out-of-pocket for medical services outside their home province, essentially denied portability.

Fair or not, that's the stinging reality of a creaking medical system - one that Ken Jamieson felt the effects of first hand. In need of a colonoscopy on the advice of his doctor late last year, he was told he would have to wait a year in his hometown of Gatineau, Que., or pay for it at a private clinic. But across the river, a mere 15-minute drive away in Ottawa, it could be performed in about a week.

Mr. Jamieson was turned away, because he was told the anesthesiologist in Ontario wasn't accepting Quebec patients.

The rates Quebec pays to physicians to deliver medical services are, on average, the lowest in Canada, which means that patients like Mr. Jamieson are refused non-urgent care when they travel to another province, are treated like foreigners, or are among the lucky few who have doctors provide medical services at a discounted rate.

"It's not what I could call fair," says Mr. Jamieson, a retired high-school teacher.

The Canadian Medical Association has called on Health Canada to enforce the portability provision of the act. The Harper government, however, doesn't appear eager to wade into what it deems a provincial matter - especially in Quebec. "Requiring patients to pay up front, and having them seek reimbursement from the covering province or territory, still satisfies the portability criterion of the act, as long as access to a medically necessary insured service is not denied due to the patient's inability to pay," said Tim Vail, spokesman for Federal Health Minister Leona Aglukkaq.

Quebec doesn't believe it's doing anything wrong, saying it has no obligation under the law to pay the additional fees demanded by physicians in other jurisdictions. A spokeswoman for the Health Minister said the government doesn't intend to change its mind.

In the midst of all this political mayhem, the lowly patient suffers.

"When we consider that many people spend thousands and thousands and thousands of dollars a year in taxes to go to a system to fund it, it is frustrating for them when they can't get care. I think it's more a reflection of a system that's no longer functioning well," said Merrilee Fullerton, president of the Academy of Medicine Ottawa.

For life and limb, patients are never denied access to the country's emergency rooms (there are interprovincial agreements to cover any in-hospital and emergency care). When it comes to non-urgent medical services, that's where the system's failings surface. All provinces, except Quebec, signed the Reciprocal Medical Billing Agreement about two decades ago, where a doctor seeing a patient from another province can bill the appropriate provincial medicare plan and be reimbursed as if the patient were from the same province.

But in allowing Quebec to simply opt out, what teeth does the Canada Health Act have? The section on portability states that Quebec must pay the rates of other provinces, or strike a deal with them to pay doctors differently. There is no such deal. The Quebec rate for an in-hospital orthopedic consult, for example, is $61, whereas the Ontario Health Insurance Plan pays about $76 and the British Columbia plan about $99.

Charles Shaver, an Ottawa specialist in internal medicine, who has led the charge to petition the federal government to intervene, said failure to enforce the CHA is evident. "When a Quebec patient is treated in Ontario or British Columbia, I think the federal government has a responsibility and some jurisdiction if the patient can't find a specialist who will accept his Quebec insurance card," Dr. Shaver said.

"To me, that's a violation of the spirit, if not the letter, of the Canada Health Act. And I think the federal government has a duty to intervene and it has abdicated this responsibility for 20 years."

Mr. Jamieson was lucky insofar as he had the means and the resolve to find a surgeon in Montreal, a roughly two-hour drive away, to perform the procedure in November. He was diagnosed with colorectal cancer shortly after. His wife, Brenda, said the process has been inconvenient. "[Health care]should be completely portable," she said.

The issue, not as high-profile as others in health care, means that it's difficult to find someone willing to pick up the torch, except for the likes of Dr. Shaver. Doctors along the Ontario-Quebec boundary are reluctant to intervene, because they could be portrayed as greedy physicians.

And physicians inside Quebec have their own issues to contend with. Louis Godin, head of the Fédération des médecins omnipraticiens du Québec, says the government needs to resolve the problems in its home province before appeasing doctors elsewhere. Two million Quebeckers don't have a family physician. Meanwhile, in the four faculties of medicine, 250 family-medical spots remained vacant over the past four years because doctors are paid roughly 30 per cent less than their counterparts elsewhere in the country. There's a lack of medical infrastructure, especially along the boundary, which has resulted in a number of doctors moving to private clinics or simply picking up and leaving for other provinces.

"If we have better access, the Quebeckers will stay in Quebec to have their care, and they don't need to go to Ontario," Dr. Godin reasons.

But until that time - and if ever that happens - doesn't Ottawa or the Quebec government have a responsibility to ensure residents living along the boundary don't fork out money for health services?

The Régie de l'assurance maladie du Québec, the province's health insurance plan, says its responsibility is to follow the rules set forth by the government. Quebec spent $169.6-million last year for medical services that residents received in other provinces, out of a total health budget of $27.9-billion. The RAMQ said it doesn't know how much extra it would cost to fully cover medical services for residents travelling to other provinces. Dr. Shaver believes it would cost about $5-million to fill the gap.

Yet, no one budges. Instead, the government encourages its residents to buy supplementary private insurance when travelling within Canada.

What is boils down to, says Doug Angus, a professor of health-care management at the University of Ottawa, is the lack of gumption on the part of those in charge. "What it really has left a number of us in the health policy area thinking about is that the feds can't really be counted on for any real leadership or vision of where this health system should be going in the future," he said.

Some residents along the Ontario-Quebec line have just come to accept that changes in policy move like tortoises in a hundred-yard dash.

Karen Lochhead, who lives in Gatineau, often pays out of pocket. She then submits her receipts to the Quebec insurance plan and is reimbursed her province's rate. She paid $2,000 last May for an artificial knee, for example, and received $1,400 back. She had no choice. She needed the procedure. At the time, it was not available in Gatineau.

"I just think if that is the way it has to go, that's the way it goes," the 69-year-old retiree says. "I don't understand the politics of why Quebec doesn't pay the same rate, but Quebec has always been different."

That difference, however, comes at a hefty price for patients.

If you're a Quebec resident needing elective orthopedic surgery from Mark Charles or many of his colleagues in Ottawa, look elsewhere. He's had such negative experiences with Quebec's health insurance plan in terms of not getting paid in full that the doctor stopped seeing Quebeckers on an elective basis. Collecting directly from patients is not part of his regular practice, he said, in part because, it "muddies the waters." Besides, demand for elective orthopedic services among Ontario patients continues to increase. "The demand for orthopedic care in the Ottawa area is huge. Why would we go beyond our province to treat Quebec residents if we are being forced to comply with this bureaucratic agenda?" Dr. Charles said.

On the other side of the country, where winter enthusiasts descend on the ski hills of Golden, B.C., general practitioner Trina Larsen Soles requires Quebeckers to pay upfront for medical care. She's given up on the RAMQ. There's been times when her office manager has submitted a bill, only to have to resubmit because the RAMQ said it hadn't received it, and was then told it wouldn't pay the amount because the bill had expired.

When it comes to non-emergency services, specialists close to her are not eager to see Quebec patients either, unless they can bill them directly. "[It]doesn't matter if I'm trying to transfer to somewhere in B.C. or Alberta, it's the same: Nobody wants them," Dr. Larsen Soles said. The Canada Health Act, in her mind, has lost some of its shine.

Blame the men and women in scrubs and white coats. Blame the politicians. For Brenda Jamieson, Ken's wife, it was a huge annoyance when she needed a specialist for her husband. She laughs when asked who she blames: "I just think the politicians and the doctors have to get together."